The recent Policy Statement on Circumcision has been criticized for
cultural bias, and it's critics have in turn been accused of the same
thing. Whether or not either party is guilty of cultural bias, it is
clear that both parties are guilty of gender bias. In weighing the
evidence with regard to recommendation, no consideration whatever has
been given to the consequences of transmitting HPV, a known cause of
cervic...

The recent Policy Statement on Circumcision has been criticized for
cultural bias, and it's critics have in turn been accused of the same
thing. Whether or not either party is guilty of cultural bias, it is
clear that both parties are guilty of gender bias. In weighing the
evidence with regard to recommendation, no consideration whatever has
been given to the consequences of transmitting HPV, a known cause of
cervical cancer, or other STDs, to women or their offspring, nor was the
pertinent literature reviewed in any depth.

Conflict of Interest:

The evolution of mammals gained speed about 65 million years ago,
when a meteorite fell on Yucatan and killed the dinosaurs. For all that we
know, at that time, the mammals had a foreskin. If the mammal foreskin
would be such a harmful piece of tissue as the pro circumcision lobbyists
claim, it certainly would have fallen off during the 65 million years of
evolution. However, mammals, including the human species, still ha...

The evolution of mammals gained speed about 65 million years ago,
when a meteorite fell on Yucatan and killed the dinosaurs. For all that we
know, at that time, the mammals had a foreskin. If the mammal foreskin
would be such a harmful piece of tissue as the pro circumcision lobbyists
claim, it certainly would have fallen off during the 65 million years of
evolution. However, mammals, including the human species, still have a
foreskin. Rat is the most successful mammal on this planet. It has a
foreskin. Evolution is merciless, and whatever mistakes it makes about the
less important organs, such as the brain or stomach, it certainly knows
best about the reproductive organs.

Therefore, the claim, that there are health benefits in excising a
piece of healthy tissue from the penis of a healthy neonate, is as absurd
as would be the claim that amputating the left little finger of a neonate
has health benefits. However, if you would make such an absurd claim,
either of the prepuce or of the left little finger, you would have to
provide the highest level of proof according to the principles of evidence
based medicine. This means several randomized controlled studies performed
by independent researchers, all having the same result. There is no such
evidence, neither of the prepuce nor of the left little finger.

The AAP is having a "Circumcision task force". This is as absurd as
having a task force for "The Routine Amputating of the Left Little Finger
of a Neonate". Is the AAP insane? To an European Paediatric Surgeon it
seems so.

Conflict of Interest:

The American Academy of Pediatrics (AAP) revised statement on male
infant circumcision claims "the benefits of circumcision may exceed the
risk of complications" but the AAP fails to recognize the sensory and
mechanical function of the human foreskin. The foreskin is richly
innervated, erogenous tissue which enhances sexual pleasure and it also
provides a unique, linear gliding mechanism during sexual intercourse. In
20...

The American Academy of Pediatrics (AAP) revised statement on male
infant circumcision claims "the benefits of circumcision may exceed the
risk of complications" but the AAP fails to recognize the sensory and
mechanical function of the human foreskin. The foreskin is richly
innervated, erogenous tissue which enhances sexual pleasure and it also
provides a unique, linear gliding mechanism during sexual intercourse. In
2009, the College of Physicians and Surgeons of British Columbia stated
"the foreskin is rich in specialized sensory nerve endings." In 2010, the
Royal Australian College of Physicians stated "the foreskin is a primary
sensory part of the penis, containing some of the most sensitive areas of
the penis" and in the same year, the Royal Dutch Medical Association
concluded "the foreskin is a complex erotogenic structure that plays an
important role in the mechanical function of the penis during sexual
acts." The AAP statement fails to consider the obstinate relationship
between structure and function as it pertains to the foreskin;
circumcision alters the structure of the penis which inevitably alters
function. The long term harm and sexual side effects of circumcision have
not been adequately studied.

The revised statement also claims "circumcision may decrease the risk
of heterosexual HIV transmission" and is supported with selective evidence
from randomized control trials from Kenya, Uganda and South Africa. These
trials reveal a number of methodological weaknesses and they contradict
larger demographic trends in global HIV prevalence. For instance, the
United States has a high prevalence of circumcision, yet has a
significantly higher rate of HIV infection compared with countries like
Sweden and Japan where the prevalence of circumcision is very low.
Behavioural factors greatly overshadow any potential protective effect of
circumcision and should be the focus of effective and ethical prevention
strategies. Even if the African trials were scientifically valid, the
evidence can not be applied to justify infant circumcision in North
America where the incidence of heterosexual HIV transmission is low.

The revised statement also claims "circumcision may decrease the risk
of urinary tract infections" yet the AAP ignores the wealth of
international medical evidence to the contrary. Even if circumcision
provided complete protection against urinary tract infections, this
practice could never be justified based on the ethical principle of
proportionality - there are effective and less destructive therapies
available for preventing and treating urinary tract infections which do
not involve the prophylactic removal of healthy genital tissue.

The AAP's revised statement ignores the inherent conflict of
circumcision with contemporary medical ethics. Infant circumcision
violates the fundamental ethical principles of autonomy, beneficence and
primum non nocere. Medical associations in the Netherlands, Finland,
Sweden, Norway, Denmark, Germany and other countries have stated that
there is no justification for performing the procedure without medical
urgency. Medical associations in these countries are calling for the
practice to stop due to ethical and human rights concerns. The AAP's new
position statement does a disservice to American parents and children.

Respectfully,
Christopher L. Guest M.D., F.R.C.P.C.

Conflict of Interest:

1)A mandatory disclosure should be made whether the person conducting
the study is himself circumscribed.Let us not be too sure of our science--
even Einstein missed discovering Quantum Mechanics even though it was
right under his nose -- by his religious beliefs.
2)It is the mob (people around the baby, like father,religious person) who
make the decision violating the Individual Rights of baby.
3)Any science which violates...

1)A mandatory disclosure should be made whether the person conducting
the study is himself circumscribed.Let us not be too sure of our science--
even Einstein missed discovering Quantum Mechanics even though it was
right under his nose -- by his religious beliefs.
2)It is the mob (people around the baby, like father,religious person) who
make the decision violating the Individual Rights of baby.
3)Any science which violates Individual Rights can only claim to be
science is way similar to the shameful claim that dialectical materialism
is a science. Again Aristotelian earth centric ideas was a "science" while
violating the Individual rights of Galileo

Conflict of Interest:

As Dr Dickerman recorded, the significance of Wright's finding for men circumcised before sexual debut (OR 0.85, 95% CI, 0.73-0.99) was marginal. No significance was found between ever-circumcised men and never-circumcised men (0.87, 0.74-1.02), and men circumcised after sexual debut were slightly but non-significantly more likely to be diagnosed with prostate cancer than never-circumcised men (1.15, 0.75-1.77...

As Dr Dickerman recorded, the significance of Wright's finding for men circumcised before sexual debut (OR 0.85, 95% CI, 0.73-0.99) was marginal. No significance was found between ever-circumcised men and never-circumcised men (0.87, 0.74-1.02), and men circumcised after sexual debut were slightly but non-significantly more likely to be diagnosed with prostate cancer than never-circumcised men (1.15, 0.75-1.77), so it is this that accounts for such correlation as was found. And as Dr. Gerald Chodak points out, the control group was not all known to be free of prostate cancer, but just assumed to be so, when undiagnosed prostate cancer (found on autopsy) is very common in older men.1

Even if the claim were valid, cutting parts off the genitals of babies to slighly reduce a cancer of old men commonly treated by watchful waiting is not good medicine. Yet this claim was widely publicised, like so many before it - and like so many cited in the AAP policy - as an indication for prophylactic circumcision of newborns.

Circumcision before first sexual intercourse was associated with a
15% reduction in risk of prostate cancer (95% confidence interval [CL],
0.73-0.99) (1). Residents of Kings County, Washington, 88.3% Caucasian and
11.7% African-American, were evaluated and data from 1754 cases of
prostate cancer were matched with 1645 controls. Multivariate logistic
regression was used to establish the relative risk of prostate cancer by...

Circumcision before first sexual intercourse was associated with a
15% reduction in risk of prostate cancer (95% confidence interval [CL],
0.73-0.99) (1). Residents of Kings County, Washington, 88.3% Caucasian and
11.7% African-American, were evaluated and data from 1754 cases of
prostate cancer were matched with 1645 controls. Multivariate logistic
regression was used to establish the relative risk of prostate cancer by
circumcision status. Infection and inflammation in the prostate may be
important mechanisms that increase the risk of subsequent development of
prostate cancer in some men. It has been demonstrated that circumcision
reduces the risk for acquiring sexually transmitted diseases.

Following the retraction of its policy on female genital mutilation
in 2010 (1,2,3,4), the American Academy of Pediatrics (AAP) seems
determined to court controversy again (5). What is puzzling is that
apparently "new scientific evidence shows the health benefits of newborn
male circumcision outweigh the risks of the procedure" - sufficient to
justify third party payment and endorsement by the American College of
Obste...

Following the retraction of its policy on female genital mutilation
in 2010 (1,2,3,4), the American Academy of Pediatrics (AAP) seems
determined to court controversy again (5). What is puzzling is that
apparently "new scientific evidence shows the health benefits of newborn
male circumcision outweigh the risks of the procedure" - sufficient to
justify third party payment and endorsement by the American College of
Obstetricians and Gynaecologists - and yet "the benefits are not great
enough to recommend routine circumcision for all newborn boys"(6).

The AAP dithers between envisioning neonatal circumcision as a
benefit rather than 'the lesser of two [harms] evils' and cannot have it
both ways: Either infant male circumcision is better for health and thus
has a 'therapeutic' indication for all or it isn't - and has to be
classified as 'cultural', 'religious', 'habitual', 'cosmetic' or
'mutilation'. Prophylactic pediatric surgery arguments are weak - we
would not accept disease eradication via routine tonsillectomy or
appendicectomy, for example, just because some children avoid problems
later and certainly not without randomised trial evidence. There are no
comprehensive and reliable statistics on the known, albeit rare, serious
risks of death and damage (7, 8). The literature on circumcision
complications is subject to underreporting and bias as it relies on case
reports and is probably compounded for non-hospital procedures. If
neonatal circumcision is beneficial, it should be recommended for all
(accepting that parents do not have to take the advice). If it is not
beneficial (or risky or harmful), then society can either (i) allow some
leeway for parents to harm their infants (with or without medical
collusion), or (ii) disallow it until boys are of an age to make their own
decisions. The latter makes particular sense as most purported benefits
relate to possibly preventing diseases and disorders, such as HIV
acquisition, that will not occur until maturity.

The key question is whether the AAP brings the medical profession
into disrepute when reading the scientific literature in an unsystematic
way and legitimising non-therapeutic procedures by 'medicalisation'.
Should we be suprised to find the practice supported by those with a
cultural, religious or financial vested interest? The conflict of interest
statements are not published with the policy. In the UK National Health
Service, despite similar official equivocation (9,10) OB-GYNs do not
perform neonatal circumcision and only 0.2% of newborn boys are
circumcised (11). Female genital cutting or mutilation is illegal in the
UK as well as the USA (12,13,14). Do newborn boys not deserve equal
protection?

Conflict of Interest:

Conflicts of interest: None declared for SB. SS is Board Certified in Pediatric Hematology/Oncology and thus performs consultations on babies with bleeding complications of circumcision, including a couple of near-miss exsanguinations.

The American Academy of Pediatrics circumcision report has many
serious deficiencies. It ignores effects of circumcision pain on infants,
two dozen surgical risks including death, functions of the foreskin,
connections between circumcision and erectile dysfunction, trauma of
circumcision, psychological harm to men, using condoms to prevent STDs,
conflicts with its own bioethics committee, lack of true informed consent,
a...

The American Academy of Pediatrics circumcision report has many
serious deficiencies. It ignores effects of circumcision pain on infants,
two dozen surgical risks including death, functions of the foreskin,
connections between circumcision and erectile dysfunction, trauma of
circumcision, psychological harm to men, using condoms to prevent STDs,
conflicts with its own bioethics committee, lack of true informed consent,
and unknown harms that have not been studied. Instead it continues the
endless search for a medical "benefit" that started in the late 1800s.
Circumcision is a solution in search of a problem.

The AAP report also conflicts with circumcision positions in other
countries that recommend against circumcision or are discussing
restricting it. Other countries recognize the inherent physical, sexual,
and psychological harm of circumcision and that it violates medial ethics
to cut off a natural, healthy, functioning body part. Ignore the report.
Just watch a circumcision video and trust your feelings.

Dr Gupta, in his response to the AAP Policy statement, implies that
the Academy recommends universal newborn male circumcision, when in fact
the policy statement clearly does not make that recommendation. Rather,
the Academy's Policy states is that the data justifies the risks compared
with benefits, leaving parents free to choose. Asked by parents, I would
now be able to report that the Academies (of Pediatrics and Ob...

Dr Gupta, in his response to the AAP Policy statement, implies that
the Academy recommends universal newborn male circumcision, when in fact
the policy statement clearly does not make that recommendation. Rather,
the Academy's Policy states is that the data justifies the risks compared
with benefits, leaving parents free to choose. Asked by parents, I would
now be able to report that the Academies (of Pediatrics and Ob/Gyn) feel
that cicumcision is acceptable, and that benefits outweigh risks. If
asked for my own professional opinion, I would recommend that purely
elective circumcision be done as a newborn, or deferred until a male can
decide for himself at age 18 years or older.

While the data presented in some of the studies cited in this
technical report are incontrovertible1, it is unclear if they can be
extrapolated to populations that are at low risk for HIV infection and
other STD. In the United States the prevalence of HIV infection and STDs
varies widely among people of different races and ethnicities. For
example, the prevalence of HIV infection among whites is 224.3 per
100,000, as c...

While the data presented in some of the studies cited in this
technical report are incontrovertible1, it is unclear if they can be
extrapolated to populations that are at low risk for HIV infection and
other STD. In the United States the prevalence of HIV infection and STDs
varies widely among people of different races and ethnicities. For
example, the prevalence of HIV infection among whites is 224.3 per
100,000, as compared to 1,715.1 per 100,000 in African Americans and 2700
per 100,000 in the African studies.2,3 The population attributable risk of
HIV and STD in uncircumcised males is likely to be lower in populations
where the prevalence of HIV is lower and higher numbers will be needed to
treat to prevent one case.3 With regard to UTI in male infants, prevalence
data on UTIs are based upon either clinic or ED studies of febrile infants
and are not population prevalence.4 UTI is found in about 8% of febrile
males below the age of 3 months and this proportion falls sharply
thereafter and the sex ratio reverses.4 Extapolating the data to all
newborns, febrile or non-febrile will lead to a lot of unnecessary
circumcisions. Rates of UTI in infants are also affected by race with
African Americans having a significantly lower rate than White Americans
in a metanalysis.4 The rates in Asian and Pacific Islanders and other
races and ethnicities are not well known. Whether the risk of STDs and
UTIs can be mitigated by proper foreskin hygiene has not been studied with
controlled trials. Hygiene habits are a modifiable behavior even among
high risk populations.5 The recommendation for universal male circumcision
is premature until effectiveness of circumcision over good penile hygiene
is studied in a randomized controlled trial. Your recommendation for
pediatricians to offer circumcision to every male newborn is an
overgeneralization. Thankfully you acknowledge that some families do not
opt for circumcision of religious and identity reason (a significant
number in the United States and an even more significant number in Europe
and other countries), and offer guidance for them about caring for an
uncircumcised penis.

Conflict of Interest:

How about the simple fact that there is absolutely no penile cancer
in circumcised males? How about because the transmission of HPV is much
reduced by circumcised males, thus presenting less of a hazard to females?
How about because circumcised males transmit less HIV and other STDs?
Scientifically it's a "no brainer." Also, 4000 years of Judaism proves
that there is no danger to the health of males of an entire cultural...

How about the simple fact that there is absolutely no penile cancer
in circumcised males? How about because the transmission of HPV is much
reduced by circumcised males, thus presenting less of a hazard to females?
How about because circumcised males transmit less HIV and other STDs?
Scientifically it's a "no brainer." Also, 4000 years of Judaism proves
that there is no danger to the health of males of an entire cultural
group. I'm less familiar with Moslems, but I think that they would testify
to the same benefit. The movement against circumcision has been much more
about politics than about a scientific approach to the health of the male
who is circumcised...as well as the sexual partners of such patients. I
find no compelling scientific and empiric evidence at all that supports a
ban such as the AAP once attempted, and which is now in place in several
European nations.

Conflict of Interest:

The American Academy of Pediatrics asserts that the health benefits
of newborn male circumcision outweigh the risks, that parents have the
right to make the circumcision decision for religious, cultural, or
other reasons, and that insurance such as Medicaid should pay for it. The
AAP is wrong on all counts.

As to the facts, the surgery risks catastrophic injury and death
(which the AAP has never acknowledged), a...

The American Academy of Pediatrics asserts that the health benefits
of newborn male circumcision outweigh the risks, that parents have the
right to make the circumcision decision for religious, cultural, or
other reasons, and that insurance such as Medicaid should pay for it. The
AAP is wrong on all counts.

As to the facts, the surgery risks catastrophic injury and death
(which the AAP has never acknowledged), and harms all boys and men without
conferring any real benefits. Among other disadvantages, it is painful,
irreversibly amputates living tissue, radically alters the appearance of
the penis, destroys normal sexual function (as anyone can see), removes
the most sensitive parts of the penis, reduces penile girth and length,
and leaves a scar. It does not benefit
infants, who are not at risk of penile cancer or STD's, and men must still
wash and practice safe sex to avoid those diseases.

As a legal matter, the rule is that physicians cannot operate on
healthy children. Boys, like girls and adults, have absolute rights under
the common law, constitutional law, and human rights law to
bodily and hence to genital integrity, to be free from harm, and to choose
their own religion or no religion. Physicians cannot take orders from
parents for reasons having nothing to do with medicine. Physicians and
parents also cannot lawfully circumcise boys because
men rarely choose circumcision for themselves. In fact, physicians and
parents have a legal duty to protect boys from circumcision.

As to Medicaid, it only covers necessary health care, not elective
cosmetic surgery. Medicaid claims for circumcision are false claims
against the government.

We condemn the AAP's new circumcision policy. We call for more than
a retraction. The AAP should tell its physicians to stop cutting body
parts off of our helpless, trusting, vulnerable children.